INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring conducted on January 21, 2026 through January 22, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Millerton Acquisition Sub, LLC DBA Bradford Recovery Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on January 21, 2026, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers to prevent the penetration of insects and rodents, and remove it, at least once a week. Upon arrival at the facility on January 21, 2026, at 10:05 a.m., it was observed that the dumpsters at the rear of the building were uncovered. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's waste removal schedule has been updated to ensure that all trash is removed from the premises no less than once per week. A group supervision session will be conducted with all staff to review the regulatory requirement for proper storage of trash and the correct use of dumpsters. This supervision will emphasize:
- Maintaining cleanliness around the dumpster area
- Ensuring dumpster lids and doors remain closed at all times
- Identifying and immediately reporting any deviations from proper waste management practices
All staff will be responsible for maintaining a clean and compliant dumpster area and for ensuring that dumpster doors remain closed. Staff will be required to complete a "Safe Catch" form and submit it to the Operations Manager whenever they observe a concern related to trash storage or dumpster conditions.
Monitoring Plan
- The Maintenance Director and Operations Manager will conduct daily and weekly inspections of the dumpster area to ensure:
o All trash is stored in noncombustible, covered containers
o Dumpster doors remain closed
o The surrounding area is free of debris, spillage, or pest attracting conditions
- The Operations Manager will review all submitted Safe Catch forms weekly and document any corrective actions taken.
- The CEO will meet weekly with the Maintenance Director and Operations Manager to review inspection logs, Safe Catch reports, and any identified compliance issues. Additional corrective measures will be implemented as needed.
Implementation Date: Monitoring and supervision activities will begin 2/16/26.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in two of the twenty-one records reviewed. Client #16 was admitted to the partial hospitalization level of care on October 08, 2025, and was still active at the time of the inspection. There was documentation that information was disclosed to a recovery house on November 19, 2025; however, the record did not contain documentation of informed and voluntary consent from the client for the disclosure of the information until January 12, 2026.Client #21 was admitted to the partial hospitalization level of care on September 19, 2025, and was still active at the time of the inspection. There was documentation that was disclosed to county probation on October 24, 2025, and November 07, 2025; however, the record did not contain documentation of informed and voluntary consent from the client for the disclosure of information. Additionally, there was documentation that information was disclosed to an outside referral source on November 10, 2025; however, the record did not contain documentation of informed and voluntary consent from the client for the disclosure of the information until November 24, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
Trainings have been assigned to reinforce internal confidentiality policies, HIPAA requirements and proper consent procedures.
A group supervision session will be conducted for all clinical staff who have direct client contact. This supervision will focus on:
- The requirement to obtain informed, voluntary client consent prior to releasing any protected information
- Proper completion and verification of consent forms
- Procedures for ensuring no information is disclosed without documented authorization
Responsible Parties
- Quality Coordinator ? Primary oversight of chart audits and verification of signed consents
- Clinical Director ? Ensures clinical staff compliance and provides corrective guidance
- Nurse Manager ? Supports monitoring of nursing related documentation and consent processes
Monitoring Plan
- The Quality Coordinator will conduct weekly chart audits to verify that all required client consents are completed and properly documented before any information is released.
o All charts will be included in the audit process; therefore, no sampling timeframe or chart count limit is necessary.
o Any missing or incomplete consents will be immediately addressed with the staff member responsible.
- The Clinical Director, Nurse Manager, and CEO will meet weekly for 90 days with the Quality Coordinator to review audit findings, identify trends, and implement corrective actions as needed to ensure sustained compliance.
Implementation Date: Monitoring and supervision activities will begin 2/16/26.
Bradford Recovery Center was able to obtain an electronically signed consent by Client #16 in the EMR on 1/12/2026. Moving forward, the proper consent forms will be monitored through the POC to ensure compliance with HIPAA standards.
Bradford Recovery Center was able to obtain an electronically signed consent by Client #21 in the EMR on 11/24/2025/2026. Moving forward, the proper consent forms will be monitored through the POC to ensure compliance with HIPAA standards.
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in one out of twenty-one records reviewed. Client #13 was admitted to the inpatient hospitalization level of care on November 18, 2025, and was still active at the time of the inspection. A release of information form for the emergency contact to be used for emergencies only, was signed and dated November 18, 2025; however, it was discovered that information was disclosed that was not specific to an emergency. The facility confirmed disclosure occurred. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
Trainings have been assigned to reinforce internal confidentiality policies, HIPAA requirements and proper consent procedures.
A group supervision session will be conducted for all clinical staff who have direct client contact. This supervision will focus on:
- The requirement to obtain informed, voluntary client consent prior to releasing any protected information
- Proper completion and verification of consent forms
- Procedures for ensuring no information is disclosed without documented authorization
Responsible Parties
- Quality Coordinator ? Primary oversight of chart audits and verification of signed consents
- Clinical Director ? Ensures clinical staff compliance and provides corrective guidance
- Nurse Manager ? Supports monitoring of nursing related documentation and consent processes
Monitoring Plan
- The Quality Coordinator will conduct weekly chart audits to verify that all required client consents are completed and properly documented before any information is released.
o All charts will be included in the audit process; therefore, no sampling timeframe or chart count limit is necessary.
o Any missing or incomplete consents will be immediately addressed with the staff member responsible.
- The Clinical Director, Nurse Manager, and CEO will meet weekly for 90 days with the Quality Coordinator to review audit findings, identify trends, and implement corrective actions as needed to ensure sustained compliance.
Implementation Date: Monitoring and supervision activities will begin 2/24/26.
Bradford Recovery center was unable to obtain the proper consent due to Client #13 successfully discharging before POC was implemented. Moving forward, the proper consent forms will be monitored through the POC to ensure compliance with HIPAA standards.
Implementation Date: Monitoring and supervision activities will begin 2/24/26.
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the dated signature of the client in two out of twenty-one records reviewed. Client #16 was admitted to the partial hospitalization level of care on October 08, 2025, and was still active at the time of the inspection. The record contained three informed and voluntary consents from the client dated November 19, 2025, for outside referral sources, that had a witness signature but did not include the dated signature of the client. The client did not sign the release until January 12, 2026. The facility confirmed disclosure had occurred prior to January 12, 2026. Client #17 was admitted to the partial hospitalization level of care on October 16, 2025, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information in the client record dated October 27, 2025, for an outside referral source, had a witness signature, but did not include the dated signature of the client. The client did not sign until November 24, 2025. The facility confirmed disclosure had occurred prior to November 24, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
Trainings have been assigned to reinforce internal confidentiality policies, HIPAA requirements and proper consent procedures.
A group supervision session will be conducted for all clinical staff who have direct client contact. This supervision will focus on:
- The requirement to obtain informed, voluntary client consent prior to releasing any protected information
- Proper completion and verification of consent forms
- Procedures for ensuring no information is disclosed without documented authorization
Responsible Parties
- Quality Coordinator ? Primary oversight of chart audits and verification of signed consents
- Clinical Director ? Ensures clinical staff compliance and provides corrective guidance
- Nurse Manager ? Supports monitoring of nursing related documentation and consent processes
Monitoring Plan
- The Quality Coordinator will conduct weekly chart audits to verify that all required client consents are completed and properly documented before any information is released.
o All charts will be included in the audit process; therefore, no sampling timeframe or chart count limit is necessary.
o Any missing or incomplete consents will be immediately addressed with the staff member responsible.
- The Clinical Director, Nurse Manager, and CEO will meet weekly for 90 days with the Quality Coordinator to review audit findings, identify trends, and implement corrective actions as needed to ensure sustained compliance.
Implementation Date: Monitoring and supervision activities will begin 2/16/26.
Bradford Recovery Center was able to obtain an electronically signed consent by Client #16 in the EMR on 1/12/2026. Moving forward, the proper consent forms will be monitored through the POC to ensure compliance with HIPAA standards.
Bradford Recovery Center was able to obtain an electronically signed consent by Client #17 in the EMR on 11/24/2025. Moving forward, the proper consent forms will be monitored through the POC to ensure compliance with HIPAA standards.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of twenty-one client records reviewed. Client #15 was admitted to the partial hospitalization level of care on October 1, 2025, and was still active at the time of the inspection. A consent form signed and dated October 1, 2025, for a government agency, did not have documentation that the client was offered a copy of the consent.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
Trainings have been assigned to reinforce internal confidentiality policies, HIPAA requirements and proper consent procedures.
A group supervision session will be conducted for all clinical staff who have direct client contact. This supervision will focus on:
- Noting in the EMR that the client was offered a copy or declined a copy of the consents signed.
- The requirement to obtain informed, voluntary client consent prior to releasing any protected information
- Proper completion and verification of consent forms
- Procedures for ensuring no information is disclosed without documented authorization
Responsible Parties
- Quality Coordinator ? Primary oversight of chart audits and verification of signed consents
- Clinical Director ? Ensures clinical staff compliance and provides corrective guidance
- Nurse Manager ? Supports monitoring of nursing related documentation and consent processes
Monitoring Plan
- The Quality Coordinator will conduct weekly chart audits to verify that all required client consents are completed and properly documented before any information is released.
o All charts will be included in the audit process; therefore, no sampling timeframe or chart count limit is necessary.
o Any missing or incomplete consents will be immediately addressed with the staff member responsible.
- The Clinical Director, Nurse Manager, and CEO will meet weekly for 90 days with the Quality Coordinator to review audit findings, identify trends, and implement corrective actions as needed to ensure sustained compliance.
Implementation Date: Monitoring and supervision activities will begin 2/16/26.
A change will occur in the EMR to include an Offered and/or Declined tab to ensure clarity that future clients were offered a copy of the consent and/or declined to receive the consent.
This will be included in the EMR by 2/24/2026.
Bradford Recovery center was unable to offer Client #13 a copy of a consent due to the client discharging before POC was implemented. Moving forward, the status of consents being Offered and Declined will be monitored through the POC to ensure compliance with HIPAA standards.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.Client #4 was admitted to the detoxification level of care on December 31, 2024, and was administratively discharged on January 04, 2025. There was no documentation that the client was notified in writing of the decision to involuntarily terminate the client ' s treatment at the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
A group supervision session will be conducted for all direct line staff to ensure proper documentation of involuntary terminations (Administrative Discharges). This supervision will include:
- The requirement to provide written notice to the client when an involuntary termination occurs
- Ensuring the written notice includes the specific reason for termination
- Proper entry of all related documentation into the EMR prior to discharge
The Administrative Discharge form will be revised to include three options: Received, Refused, or Other.
- If "Other" is selected because the client is unable to receive or refuse the form, the Administrative Discharge notice will be mailed to the client.
- If no home address is available, staff will document all reasonable efforts made to provide the client with a copy based on their circumstances.
- All actions taken will be documented in the EMR.
All clinical staff will be responsible for ensuring that the required documentation is completed and entered into the EMR before the client is discharged from the facility.
Responsible Parties
- Clinical Staff ? Completion and entry of all required termination documentation
- Quality Coordinator ? Oversight of chart audits and verification of compliance
- Clinical Director ? Ensures clinical staff adherence to procedures
Monitoring Plan
- The Quality Coordinator will audit all charts involving premature or involuntary discharges to verify that:
o Written notice of termination is present
o The reason for termination is documented
o The Administrative Discharge form is completed with the appropriate Received/Refused/Other designation
o Documentation of mailing or attempted delivery is included when applicable
- The Clinical Director, Nurse Manager, and CEO will meet weekly for 90 days with the Quality Coordinator to review audit findings, identify trends, and implement corrective actions as needed to ensure sustained compliance.
Implementation Date: Monitoring and supervision activities will begin 2/16/26.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative documents, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel. The facility documentation showed the presence of fire personnel on January 17, 2025, May 03, 2025, June 15, 2025, and October 19, 2025. The facility did not report the incidents to the Department within the regulatory timeframe.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
The facility has implemented a procedure ensuring that any unusual incident requiring the presence of police, fire, or ambulance personnel is reported to DDAP within 72 hours (3 business days), in accordance with regulatory requirements.
The Quality Manager has reviewed the reporting process with the Quality Coordinator to ensure that all incidents are identified promptly, documented accurately, and submitted within the required timeframe. This revised process has been in effect since 1/22/26.
Monitoring Plan
The Quality Manager will oversee the Quality Coordinator's incident reporting activities daily to ensure:
- All unusual incidents are identified
- Reports are completed accurately
- Reports are submitted to DDAP within the required 72 hour timeframe
The CEO meets weekly for 90 days with the Quality Manager and Quality Coordinator beginning the week of 2/16/26 to review:
o All incident reports submitted
o Timeliness of submissions
o Any missed or delayed reports
o Additional corrective actions needed to maintain compliance
- Implementation Date: Monitoring and supervision activities will begin 2/16/26.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on the review of client records, the facility failed to ensure counseling was provided to a client on a regular and scheduled basis to include individual counseling, at least twice weekly in three of seven clients reviewed.Client #15 was admitted on October 01, 2025, and was still active at the time of the inspection. The facility only documented one individual counseling session for the weeks of October 05, 2025 through October 11, 2025, October 12, 2025 through October 18, 2025, October 26, 2025 through November 01, 2025, November 02, 2025 through November 08, 2025, and December 28, 2025 through January 03, 2026. Additionally, there was no documentation for any individual counseling sessions for the weeks of November 23, 2025 through November 29, 2025, and December 21, 2025 through December 27, 2025. Client #16 was admitted on October 08, 2025 and was still active at the time of the inspection. The facility only documented one individual counseling session for the weeks of October 12, 2025 through October 18, 2025, and October 19, 2025 through October 25, 2025. Additionally, there was no documentation of any individual counseling sessions for the week of November 09, 2025 through November 15, 2025. Client #17 was admitted on October 16, 2025 and was still active at the time of the inspection. The facility only documented one individual counseling session for the week of October 26, 2025 through November 1, 2025, November 09, 2025 through November 15, 2025, and November 16, 2025 through November 22, 2025. Additionally, there was no documentation of any individual counseling sessions for the week of November 23, 2025 through November 29, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
A group supervision session will be conducted with all PHP clinical staff to review the treatment service standard requirement This supervision will cover:
- Scheduling expectations for individual sessions
- Documentation standards for session completion
- Timely entry of all counseling notes into the EMR
Responsible Parties
- PHP Clinical Staff ? Responsible for completing and documenting required individual sessions
- Quality Coordinator ? Responsible for daily and weekly chart audits
- Clinical Director ? Oversight of clinical compliance and corrective follow up
Monitoring Plan
- The Quality Coordinator will conduct weekly audits of all PHP charts to verify that:
o Two individual counseling sessions are completed each week
o Documentation is entered into the EMR accurately and in a timely manner
- Staff performance and documentation trends will be reviewed during FLASH with leadership to address any emerging issues.
- The Clinical Director will meet weekly for 90 days with the Quality Coordinator to review audit findings, identify patterns of noncompliance, and implement corrective actions as needed to ensure sustained adherence to the regulation.
Implementation Date: Monitoring and supervision activities will begin 2/16/26.
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709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the facility to include follow up information in three out of three applicable records reviewed. Client #18 was admitted on November 21, 2024, and discharged on January 10, 2025. There was no documentation of follow-up information in the record at the time of the inspection. Client #19 was admitted on December 19, 2024, and discharged on July 14, 2025. There was no documentation of follow-up information in the record at the time of the inspection. Client #20 was admitted on December 02, 2024, and discharged on January 06, 2025. There was no documentation of follow-up information in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
Bradford Recovery Center will now conduct all follow up calls internally, within alignment of DDAP standards, 7 days post planned discharge and 14 days post unplanned discharge
Training to the Quality Coordinator has been provided on:
- The required timeframe for follow up calls
- The content and purpose of follow up communication
- Proper documentation standards
All follow up calls will be documented in the EMR, including attempts, successful contacts, and any relevant information obtained.
The Quality Coordinator began completing follow up calls effective 2/4/26.
Responsible Party
- Quality Coordinator ? Responsible for completing all follow up calls and documenting them in the EMR.
Monitoring Plan
- The Quality Coordinator will complete, and document all follow up calls for discharged clients within the required 30 day timeframe.
- The CEO will meet weekly with the Quality Coordinator to review:
o Follow up call logs
o Documentation in the EMR
o Any missed or delayed follow ups
o Trends or barriers requiring corrective action
- Implementation Date: Monitoring and supervision activities will begin 2/16/26.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Follow-up information.
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Observations
Based on review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow up information in four out of four applicable records reviewed. Client #1 was admitted on October 03, 2025, and discharged on October 07, 2025. There was no documentation of follow-up information in the record at the time of the inspection. Client #2 was admitted on August 02, 2025 and discharged on August 05, 2025. There was no documentation of follow-up information in the record at the time of the inspection. Client #3 was admitted on January 02, 2025 and discharged on February 10, 2025. There was no documentation of follow-up information in the record at the time of the inspection. Client #4 was admitted on December 31, 2024, and discharged on January 04, 2025. There was no documentation of follow-up information in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
Bradford Recovery Center will now conduct all follow up calls internally, within alignment of DDAP standards, 7 days post planned discharge and 14 days post unplanned discharge
Training to the Quality Coordinator has been provided on:
- The required timeframe for follow up calls
- The content and purpose of follow up communication
- Proper documentation standards
All follow up calls will be documented in the EMR, including attempts, successful contacts, and any relevant information obtained.
The Quality Coordinator began completing follow up calls effective 2/4/26.
Responsible Party
- Quality Coordinator ? Responsible for completing all follow up calls and documenting them in the EMR.
Monitoring Plan
- The Quality Coordinator will complete, and document all follow up calls for discharged clients within the required 30 day timeframe.
- The CEO will meet weekly with the Quality Coordinator to review:
o Follow up call logs
o Documentation in the EMR
o Any missed or delayed follow ups
o Trends or barriers requiring corrective action
- Implementation Date: Monitoring and supervision activities will begin 2/16/26.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the facility to include follow up information in one out of one applicable record reviewed. Client #14 was admitted on September 06, 2025, and discharged on September 11, 2025. There was no documentation of follow-up information in the record at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
Bradford Recovery Center will now conduct all follow up calls internally, within alignment of DDAP standards, 7 days post planned discharge and 14 days post unplanned discharge
Training to the Quality Coordinator has been provided on:
- The required timeframe for follow up calls
- The content and purpose of follow up communication
- Proper documentation standards
All follow up calls will be documented in the EMR, including attempts, successful contacts, and any relevant information obtained.
The Quality Coordinator began completing follow up calls effective 2/4/26.
Responsible Party
- Quality Coordinator ? Responsible for completing all follow up calls and documenting them in the EMR.
Monitoring Plan
- The Quality Coordinator will complete, and document all follow up calls for discharged clients within the required 30-day timeframe.
- The CEO will meet weekly with the Quality Coordinator to review:
o Follow up call logs
o Documentation in the EMR
o Any missed or delayed follow ups
o Trends or barriers requiring corrective action
- Implementation Date: Monitoring and supervision activities will begin 2/16/26.
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